Thinda, Sumeer MD; Vaphiades, Michael S. DO; Mawn, Louise A. MD
Vanderbilt Eye Institute (ST, LAM), Vanderbilt University Medical Center, Nashville, Tennessee
Department of Ophthalmology (MSV), University of Alabama, Birmingham, Alabama.
Address correspondence to Louise A. Mawn, MD, Vanderbilt Eye Institute, 2311 Pierce Avenue, Nashville, TN 37232; E-mail: email@example.com
Supported in part by a Research to Prevent Blindness unrestricted grant to the Vanderbilt Eye Institute, Physician Scientist Award to L.A. Mawn and the University of Alabama at Birmingham Department of Ophthalmology. The authors have no financial interest in any material discussed in this manuscript.
The authors report no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTMLfull text and PDF versions of this article on the journal's Web site (www.jneuro-ophthalmology.com).
Abstract: Blepharoplasty with fat repositioning is a technique used to fill the tear trough in the aging lower eyelid. We describe a patient who underwent transcutaneous lower eyelid blepharoplasty with fat repositioning who subsequently developed mechanical oscillopsia in the right eye exacerbated by facial movement. Surgical exploration revealed cicatrix between the inferior oblique muscle and the anterior superficial musculoaponeurotic system. Excision of the scar bands led to immediate amelioration of symptoms. When performing blepharoplasty with fat repositioning, it is essential to be aware of the anatomic location of the inferior oblique in the anterior inferomedial orbit to avoid incarceration of this muscle.
Cosmetic blepharoplasty with fat repositioning is a commonly performed procedure to fill tear trough deformity and create a more youthful appearance (1–3). Complications of this procedure include temporary hardening of the fat pedicle, temporary skin irregularities, and diplopia as a result of fibrous bands causing restrictive ocular misalignment (2–4).
Oscillopsia is a subjective sensation of to-and-fro movement of the environment usually secondary to a neurological or mechanical etiology. We report a patient who underwent 4 eyelid transcutaneous blepharoplasty with fat repositioning and immediately developed oscillopsia after the procedure. The etiology of the patient’s oscillopsia was mechanical in nature because of multiple areas of cicatrix formation.
A 71-year-old woman presented with a 2-year complaint of vertical oscillopsia in the right eye, which occurred immediately after transcutaneous lower eyelid blepharoplasty with fat repositioning. The oscillopsia was intermittent and precipitated by downgaze, chewing, moving the mouth or by pressing on the right cheek or right upper lip (see Video 1, Supplemental Digital Content, http://links.lww.com/WNO/A52). The operative procedure had been performed under general endotracheal anesthesia along with local xylocaine/epinephrine injection (concentration and dose not recorded). A transcutaneous subciliary incision was made and a suborbicularis muscle plane of dissection was carried to the infraorbital rim. A subperiosteal plane of dissection was then developed and extended into the cheek area. The periosteum was reflected from the lateral orbital rim and a drill hole was created at the lateral orbital rim. The fat was released from all 3 compartments of both lower eyelids and used to fill the tear trough. The fat pedicles were draped over the infraorbital rim and secured with 4-0 and 5-0 Polyglactin 910 sutures (Ethicon, Inc, Somerville, NJ). The lower eyelid was advanced in a cephalad direction and the periosteum was secured to the previously placed drill hole using 5-0 nylon sutures (Ethicon Inc). A lateral canthoplasty was performed and a muscle transposition flap of the orbicularis muscle was created to further support the lower eyelid. The skin was then closed with 5-0 Polyglactin 910 and 6-0 silk sutures (Ethicon Inc).
Medical history was noncontributory, and the patient was not on any medications. Visual acuity was 20/30 in the right eye and 20/25 in the left eye, with normal color vision bilaterally. Pupillary testing, automated visual fields, and funduscopy were normal. Extraocular movements were intact, and the patient was orthotropic in all positions of gaze (Fig. 1). In primary position, double Maddox rod testing demonstrated a small right hypotropia with 3° of excyclotorsion of the right eye. There was increased displacement of the double Maddox rod lines with cheek movement. There was no ptosis, proptosis, lagophthalmos, or eyelid movement abnormality. Cranial nerve examination was otherwise normal.
The patient had undergone orbital ultrasound, contrast-enhanced magnetic resonance imaging of the brain and orbits with and without fat suppression, magnetic resonance angiography of the neck, and computed tomography of the orbits, which reportedly were all normal.
Clinical suspicion was high for incarceration of the inferior oblique sheath in the anterior lamella of the lower lid. Right inferior orbitotomy revealed multiple areas of cicatrix from the septal tissue to the orbital rim, the anterior superficial musculoaponeurotic system (SMAS) to the orbital rim, and from the inferior oblique muscle to the anterior SMAS tissue (Fig. 2). The scar tissue was meticulously dissected out and AlloDerm (LifeCell Corporation, Branchburg, NJ) was placed to act as a barrier to further scarring of the inferior oblique muscle to the facial tissues. The patient immediately noted resolution of oscillopsia and at 3-month follow-up examination, she remained asymptomatic.
Our patient developed cicatricial tethering of the right inferior oblique muscle to the anterior SMAS as a complication of transcutaneous lower eyelid blepharoplasty with fat repositioning. The SMAS invests the facial mimetic muscles, distributes facial muscle contractions, and facilitates facial expression. Our patient’s symptom of oscillopsia with lower facial movement raised the possibility of relationship between the SMAS and the ocular motility system. The examination was consistent with the involvement of a torsional extraocular muscle, specifically the inferior oblique. When cicatrix connecting the right inferior oblique and SMAS was severed surgically, the patient’s symptoms resolved.
Fat repositioning is a commonly performed procedure used to rejuvenate the periorbital area and improve the tear trough deformity. This age-related deformity is due to loss of fat over the orbital rim and the descent of midfacial structures (1–3). Excision of orbital fat during a blepharoplasty can lead to exacerbation of this deformity. Fat repositioning, however, allows for amelioration of this deformity and a more youthful appearance. This technique is typically performed via a transconjunctival approach with dissection to the orbital rim where either a subperiosteal or supraperiosteal plane can then be used for further dissection. After the area is undermined, a fat pedicle is transposed over the orbital rim and fixated with sutures (1–3).
Complications of lower eyelid blepharoplasty include lid malposition, hemorrhage, visual loss, diplopia, and strabismus involving the inferior oblique and inferior rectus muscles (5,6). These impairments can be temporary because of hemorrhage or edema or permanent as a result of direct injury to the muscle (surgical or anesthetic myotoxicity), or incarceration of orbital tissue (5,6). Direct surgical muscle injury or anesthetic myotoxicity would not lead to adhesions between extraocular muscle and the SMAS. Reported complications of lower eyelid blepharoplasty with fat repositioning include temporary hardening of the fat pedicle, temporary skin irregularities and vertical diplopia, torsional diplopia and restriction of ocular movements as a result of cictricial changes (2–4).
We are unaware of previous cases of mechanical oscillopsia as a complication of a lower eyelid blepharoplasty with fat repositioning. Appreciation of the anatomic location and the action of the inferior oblique muscle and possibly performing forced ductions intraoperatively after fat repositioning, may help avoid incarceration of the inferior oblique muscle (2,4,7).
1. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg. 1995;96:354–362.
2. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg. 2000;105:743–748; discussion 749–751.
3. Kawamoto HK, Bradley JP. The tear “TROUF” procedure: transconjunctival repositioning of orbital unipedicled fat. Plast Reconstr Surg. 2003;112:1903–1907; discussion 1908–1909.
4. Goldberg RA, Yuen VH. Restricted ocular movements following lower eyelid fat repositioning. Plast Reconstr Surg. 2002;110:302–305; discussion 306–308.
5. Harley RD, Nelson LB, Flanagan JC, Calhoun JH. Ocular motility disturbances following cosmetic blepharoplasty. Arch Ophthalmol. 1986;104:542–544.
6. Syniuta LA, Goldberg RA, Thacker NM, Rosenbaum AL. Acquired strabismus following cosmetic blepharoplasty. Plast Reconstr Surg. 2003;111:2053–2059.
7. Mowlavi A, Neumeister MW, Wilhelmi BJ. Lower blepharoplasty using bony anatomical landmarks to identify and avoid injury to the inferior oblique muscle. Plast Reconstr Surg. 2002;110:1318–1322; discussion 1323–1314.